Integrated care management program generates 3-to-1 return on investment
Integrated care management program generates 3-to-1 return on investment
Team approach ensures members get all the care they need
An integrated care management program has resulted in a return on investment of greater than 3-to-1 for Blue Cross and Blue Shield of North Carolina.1
On average, annual claims expense related to managing members’ conditions is $331 less per person than what it would have been without the care management programs, says Sandra Stephenson, RN, CCM, catastrophic case manager for the Chapel Hill, NC, insurer.
The company’s care management department provides comprehensive catastrophic case management, disease-specific case management, and prenatal case management.
The size of the department has doubled over the past four years and continues to grow, Stephenson says. Most of the company’s case managers become certified within two years of employment, she adds.
The company’s disease-specific case managers coordinate care for patients with asthma, diabetes, cardiac problems, and congestive heart failure (CHF). The plan also offers case management for pregnant women who request it.
The catastrophic case managers work with patients who need intensive, short-term case management, such as those who have been hospitalized, catastrophically injured, or those who have multiple visits to the emergency department or their physician in a short time.
Here are some results of the program:
- A 38% increase in the number of asthmatics who use a peak-flow meter after they have participated in the Member Health Partnerships-Asthma program for six months.
- A 14% decrease in the number of days that infants spend in the neonatal intensive care unit from 1998 to 2003.
- A 7% increase in the number of diabetics who get the recommended hemoglobin A1C tests over a three-month period.
- A 38% increase in the percentage of CHF patients who weigh themselves every day.
When members are hospitalized, the health plan’s on-site nurses review their charts and refer them to the case management triage nurses if they appear to be appropriate for the services.
The triage nurse refers appropriate cases to the catastrophic case managers, who conduct an extensive assessment, including a history of any chronic diseases. If the member has diabetes or another chronic disease, the triage nurse refers him or her to the appropriate chronic disease program.
If the member is a smoker and wants to quit, he or she is referred to the plan’s smoking cessation program.
The health plan’s case managers work as a team to ensure that members get all the care they need, referring them to other segments of the case management program when necessary.
When members qualify for more than one case management program, the case managers work together to decide which one should take the lead in managing the care.
For instance, in the case of a diabetic member who is traumatically injured, the catastrophic case manager would start out coordinating the care and follow the patient through rehabilitation, a skilled nursing facility, and home with therapy, working with the patient to get his or her diabetes under control. The diabetes case manager could take over any time it’s appropriate, even when the member still is in the hospital. The diabetes case manager would become involved right away if the member is hospitalized for a diabetes-related condition, such as imputation, ulceration, cellulitis, or blood sugar issues.
Continuity of care
When the member is back home, the disease management nurse would assume primary responsibility.
"Once the trauma issues are settled, the member is in a position to need more case management for his or her diabetes," Stephenson says.
In most cases, it’s more effective to have just one nurse calling the member for consistency.
The exception is members who are homebound and look forward to getting calls from case managers, points out Jan Calland, RN, MSN, CCM, diabetes case manager. In these cases, both the catastrophic case manager and the disease management case management may work with the patient.
The case managers in all programs work in close proximity to each other. The health plan’s software allows them to see documentation on members being followed by other case managers if they have the name or policy number.
"When we do specific documentation, we try to capture everything we’ve done with that member. For instance, I do a lot of education with my traumatically injured patients and document it so when the disease management nurse picks up the case, they’ll know where to start and not duplicate," Stephenson says.
"We work hard on continuity of care and reinforcing what other case managers are working on. It’s a team approach, and we work together to make sure the members get what they need," she adds.
The team can pull in other clinicians when needed. For instance, social workers collaborate with the case managers when members need help with financial issues and finding community resources. Dietitians work with members in the program to help them modify their diet and make other lifestyle changes.
Laurie Champagne, RN, CCM, a prenatal case manager, often encounters pregnant women with chronic illnesses such as diabetes or asthma.
She enrolls them in the appropriate disease management program and works with a disease management nurse to help them get the condition under control, providing peak-flow meters or blood testing kits as necessary.
"In most cases, I consult with the disease management nurse during the pregnancy because it’s more effective to have just one case manager calling the member and organizing the care. After the baby is born, I’ll ensure that they are transferred to a disease management case manager," Champagne reports.
Preventive care
Case management is part of the health plan’s strong focus on preventive care. The company has expanded its Healthy Lifestyle Choices program to cover weight loss and obesity treatment.
"The nurses are all very excited about coverage of weight loss programs. It’s very cutting edge and complements other aspect of the patients’ health that we are working on," Calland says.
Most of the members in the disease-specific case management programs are identified through claims data and by surveys that are sent to everyone the system flags with a specific disease. When they complete the survey, they indicate if they want to speak with a case manager.
In some cases, the catastrophic case managers refer members to the disease specific programs. For instance, if a member is hospitalized with a stroke and also has diabetes, the catastrophic case manager coordinates his or her care in the beginning when diabetes is not a dominant issue, then refers the member to the diabetes case management program.
"In the beginning, stroke or heart attack patients with diabetes are usually referred to a hospital-based diabetes educational program. In these cases, we back off until the classes are over and then make ourselves available for support," Calland says.
Once a member is enrolled in the diabetes management program, the case managers call them biweekly or monthly for the first few months.
The case managers have been educated in motivational interviewing to help them find out what the members’ issues are and work with them to set goals.
The case managers in the diabetes program make calls on a random basis to members in the program, often identifying members whose blood sugar has been out of control for a while, Calland says.
"We tell them to make an appointment with their doctor right now, and in some cases, we make a call to the doctor. We know that if we had not intervened, they would have made an emergency room visit," she says.
Catastrophic case management
The program generates soft savings but there’s no way to come up with hard data, Calland notes.
"We know that high blood sugar puts people in the emergency room pretty frequently. By making a simple phone call, we can keep them out of the emergency room," she says.
The catastrophic case managers take a proactive approach to care, interacting with the members while they still are in the hospital, ensuring that their discharge needs are met.
"If we don’t find out about these members while they are in the hospital, they may go into acute rehabilitation or a skilled nursing facility before we get to talk to them. We’re in continuous touch with the facility in whatever level of care they are in so that we know what their needs will be when they get home and can proactively work to make sure they get whatever durable medical equipment or services they need," Stephenson adds.
For instance, the family of a wheelchair-bound patient may not think about installing a wheelchair ramp at their home.
"Health care is a puzzle, and sometimes pieces get left out. We work with the family to try to get everything the patient needs to make the transition to home," Stephenson says.
When patients are discharged from the hospital to home, the catastrophic case managers get in touch with them and help with any post-discharge issue. In some cases, the patient is being treated by several different specialists and may have pharmaceutical issues.
"One member was on three different drugs of the same kind. In this and other cases, we work with the physicians to get them to streamline the drugs so the patient will be safe," Stephenson recalls.
The catastrophic case managers often call in social workers to assist when needed. For instance, some severely injured patients can’t return to work and face major financial issues, which cause high levels of stress.
"We also have worked with elderly patients who have to decide if they are going to buy food or buy medications. In those cases, we call on the social workers to assist," Stephenson says.
The catastrophic case managers intervene when members have multiple emergency department (ED) visits or hospitalization.
For instance, one member with diabetes and comorbidities had visited the ED 52 times in a two-month period.
When Stephenson investigated, she found out that his primary care physician was referring the member to the ED because he made frequent appointments to see the physician.
The member told Stephenson that he felt uncomfortable with his male physician. She found a female physician who was willing to see the patient every day for two weeks and gradually weaned him from his dependency on the physician.
Before the plan established its CHF program, Stephenson worked with a member who made frequent visits to the hospital and had to be intubated twice in a three-month period.
Stephenson worked with the cardiologist, who agreed to see the member every day for a while. Stephenson also called the member and had her weigh herself while she was on the phone.
"If she gained more than 2 pounds, I’d call the physician. We got her to the point that when she gained weight, she would call the doctor and get him to adjust her Lasix," she says.
The member was discharged from the catastrophic case management program after a few months and, to Stephenson’s knowledge, has not had another ED visit.
The goal of the catastrophic case managers is to transfer or close the case in four months.
"Sometimes we carry them longer if they have needs," Stephenson says.
In the case of members who are in catastrophic case management more than once, such as cancer patients who have a recurrence, the original case manager handles the care whenever possible.
All pregnant members have the opportunity to work with a prenatal case manager if they choose.
When the plan gets a claim or a question from a physician indicating that a member is pregnant, the prenatal case managers send out a health survey that includes questions about past pregnancies and their current health.
The health plan mails educational materials to members at various stages of pregnancies and offers them a choice of two books on pregnancy and child care from a list of about a dozen.
"Sometimes it’s a young, healthy first-time mother or someone who’s 40 with infertility problems or a woman who is having her third or fourth child," Champagne says.
"The literature shows that working with a nurse is the most successful way to avoid preterm labor. Even the newer technology doesn’t work as well," Champagne says.
The nurses educate the members on signs and symptoms of preterm labor and what steps members can take to prevent going into labor early, such as getting adequate hydration and watching for infections.
Since the program began, the plan has experienced a 15% decrease in the number of days infants spend in the neonatal intensive care unit.
Note
- The return on investment calculation is performed using the following methodology: Aggregate hard savings are identified for the reporting time frame. Program costs are identified for the reporting time frame. Hard savings divided by program expenses=return on investment.
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